Tomomi Ushiyama

Laparoscopic Adrenalectomy: Clinical Experience with 12 Cases

Laparoscopic adrenalectomy is a new procedure for the treatment of adrenal tumors. The clinical experience with this operation in 12 patients is reported. While adrenal tumors are relatively small and seem to be good candidates for laparoscopic surgery, this procedure is difficult because of the anatomical location. In our study laparoscopic adrenalectomy appeared to be successful, although massive bleeding occurred in 3 patients. These problems should be overcome as the technique is improved and new laparoscopic instruments are introduced.

COMPARISON OF 3 SURGICAL APPROACHES TO LAPAROSCOPIC ADRENALECTOMY: A NONRANDOMIZED, BACKGROUND MATCHED ANALYSIS

PURPOSE To clarify the characteristics of surgical approaches to laparoscopic adrenalectomy we performed background matched analysis of clinical outcomes of the 3 approaches. MATERIALS AND METHODS From February 1992 to July 2000 we performed 118 laparoscopic adrenalectomies in 115 patients with adrenal tumors. For these operations we used the anterior transperitoneal approach in 46 patients, the lateral transperitoneal approach in 32 and the lateral retroperitoneal approach in 40. RESULTS To exclude the learning curve effect we eliminated our initial 20 patients treated with the anterior transperitoneal approach. To allow background matching of the 3 groups we also excluded 14 patients with tumors more than 5 cm., 6 who underwent conversion to open surgery and 1 patient who required 5 days of bed rest for retroperitoneal hematoma caused by bleeding from a trocar port. The final analysis included 16, 25 and 36 cases managed via the anterior transperitoneal, lateral transperitoneal and lateral retroperitoneal approach, respectively. Average operative time was significantly shorter for the lateral transperitoneal approach. Postoperative recovery was not significantly different in the lateral transperitoneal and lateral retroperitoneal groups. Postoperative complications included mild paralytic ileus in 2 patients and shoulder tip pain, probably peritoneal irritation due to carbon dioxide insufflation and bowel preparation, in 4 in the transperitoneal groups. Our results imply that the easiest procedure is the lateral transperitoneal approach but the lateral retroperitoneal approach is slightly less invasive. CONCLUSIONS Although it is important to remember that this study was not a prospective randomized trial and, thus, had from certain biases, we believe that if a tumor is more than 5 cm. and/or the surgeon is not yet skilled in laparoscopic adrenalectomy, the lateral transperitoneal approach is the most suitable method. If the surgeon has performed at least 20 operations, the adrenal tumor is unilateral and the lesion is less than 5 cm., the lateral retroperitoneal approach seems to be more suitable because of its minimally invasive nature. The lateral retroperitoneal approach is also preferred in patients with a history of upper abdominal surgery. With improvements in technique and new instruments the time required for the lateral retroperitoneal approach has been significantly decreased.

Hazards of laparoscopic adrenalectomy in patients with adrenal malignancy.

We report the clinical outcomes of 2 patients undergoing laparoscopic adrenalectomy for adrenal malignancy. CASE REPORTS Case 1. A 50-year-old woman had Cushings syndrome due to left adrenal adenoma. Computerized tomography showed a 5 x 4.5 cm. tumor in the left adrenal gland that was slightly irregular (part A of figure). The tumor was removed en bloc without any damage by laparoscopic adrenalectomy. However, local recurrence and abdominal dissemination of the tumor occurred about 19 months after laparoscopic surgery. When the previously resected adrenal specimen was carefully reexamined, the diagnosis was changed to adrenocortical carcinoma. Although combination chemotherapy was administered, the patient died about 3 years aRer the first laparoscopic procedure. 1 Case 2. A 62-year-old man had left adrenal metastasis from poorly differentiated adenocarcinoma of the lung. Magnetic resonance imaging showed a 5.5 X 4.0 cm. tumor in the leR adrenal gland (part B of figure). We attempted to perform retroperitoneal adrenalectomy but the procedure had to be changed to open surgery (en bloc removal with an upper part of the kidney) because of severe adhesions between the kidney and adrenal tumor. The patient died of multiple metastases from lung cancer about 8 months after the surgery.

Complications of Laparoscopic Adrenalectomy in 75 Patients Treated by the Same Surgeon

Objective: We analyzed the complications of endoscopic adrenalectomy. Methods: We retrospectively reviewed the operative and postoperative complications among 75 patients with adrenal tumors who underwent endoscopic adrenalectomy by the same surgeon. Results: Five patients (6.7%) were converted to open surgery. Of these, there were 2 with metastatic adrenal carcinoma, and 1 with adrenal tuberculosis. A total of 21 patients (28%) had 24 complications (32%). There was no mortality. As for access and pneumoperitoneum-related complications, 5 cases of subcutaneous emphysema and 3 of radiating shoulder pain occurred. Intraoperative complications included 2 cases of vascular injury, 2 of organ injury, and 4 of massive bleeding (>500 ml). Postoperative complications included 2 cases of mild paralytic ileus, 2 asthma, and 1 each of angina, wound infection, retroperitoneal hematoma, and contralateral atelectasis. Except for the patients with adrenal malignancy and adrenal tuberculosis, 71% of the complications occurred among the initial 25 patients with laparoscopic adrenalectomy and 80% occurred in the initial 10 retroperitoneoscopic patients. Conclusion: Although endoscopic adrenalectomy is a valuable alternative to open surgery, it should be done by a skilled laparoscopist in patients with adrenal inflammatory lesions or malignancy. Careful patient selection and correct choice of surgical approach according to the tumor size and the patient’s condition are the most important points for avoiding the complications of laparoscopic adrenalectomy.

RETROPERITONEOSCOPY ASSISTED LIVE DONOR NEPHRECTOMY: THE INITIAL 2 CASES

PURPOSE We investigated retroperitoneoscopy assisted nephrectomy in living kidney donors. MATERIALS AND METHODS Gasless surgery was performed with a 10 cm. upper abdominal pararectus skin incision and 2 trocars. The abdominal wall was lifted using special retractors and the kidney was removed via the pararectus incision. RESULTS The operating time, blood loss, warm ischemic time and postoperative recovery period for the 2 donors were a mean of 210 minutes, 102 ml., 3.5 minutes and 4.5 days, respectively. There were no operative or postoperative complications. Postoperative recovery was significantly more rapid than after open donor nephrectomy. There were no differences with regard to graft biopsy findings or postoperative graft function between retroperitoneoscopy assisted and open donor nephrectomy. CONCLUSIONS Retroperitoneoscopy assisted nephrectomy could be advantageous for healthy kidney donors since it is minimally invasive.

Gasless Laparoscopy-Assisted Nephrectomy without Tissue Morcellation for Renal Carcinoma

PURPOSE The efficacy of gasless laparoscopy-assisted nephrectomy for renal tumors is determined. MATERIALS AND METHODS Seven patients with renal tumors underwent gasless laparoscopy-assisted nephrectomy. The results were compared to those of patients undergoing open nephrectomy. RESULTS Although a long operating time was required, convalescence was significantly more rapid. En bloc removal of the kidney and complete pathological examination were possible in all patients. CONCLUSIONS This procedure may be useful for the treatment of noninvasive renal carcinoma, especially in patients with cardiovascular and/or ventilatory complications. However, long-term followup is necessary to confirm the efficacy in preventing recurrence.

PSA Value Adjusted for the Transition Zone Volume in the Diagnosis of Prostate Cancer

Background: The aim of the present study was to improve the accuracy of the prostate‐specific antigen (PSA) density for detecting prostate cancer by using the transition zone (TZ) volume instead of the total prostate volume.

Operative Fiberoptic Nephroureteroscopy: Removal of Upper Ureteral and Renal Calculi

We tested 2 prototypes of an operating fiberoptic nephroureteroscope, measuring 3.5 and 4.5 mm. in diameter, that have an adequate working channel for auxiliary instruments and irrigation. Difficulty in passing the fiberscope through the ureteral orifice was overcome by dilation with balloon and polytetrafluoroethylene (Teflon) dilators. Our initial trial for stone retrieval under fiberscopic control was performed on 21 patients with upper ureteral and renal calculi. A stone was removed successfully in 15 of the 21 patients (71 per cent). After electrohydraulic lithotripsy calculi were extracted successfully in 9 of 11 patients (82 per cent). Three patients suffered ureteral perforation. The fiberscope was especially helpful when an upper ureteral stone moved back to the kidney during stone manipulation.

Comparison of pharmacokinetics of mycophenolic acid and its glucuronide between patients with lupus nephritis and with kidney transplantation.

The pharmacokinetics of mycophenolic acid (MPA) and its glucuronide (mycophenolic acid phenolic glucuronide, MPAG) in lupus nephritis (LN) have not been fully characterized. The aim of this study was to evaluate the pharmacokinetics of MPA and MPAG in LN patients by comparing the pharmacokinetics with those of kidney transplant (KT) recipients. Six LN patients (World Health Organization class IV and V) and 24 KT recipients [8 recipients treated with tacrolimus (Tac) and 16 with cyclosporine (CyA)] during the early posttransplantation period were enrolled. Pharmacokinetic parameters of MPA and MPAG were compared between LN patients and Tac-treated or CyA-treated KT recipients. The area under the concentration-time curve (AUC0-12) of MPA normalized to mycophenolate mofetil (MMF) dose (mg/kg) was significantly lower in LN patients and CyA-treated KT recipients than in Tac-treated KT recipients [median (range), 2.19 (0.87-4.23), 2.36 (1.13-5.74), and 4.86 (3.25-6.75) μg·h/mL per mg/kg, P < 0.05 and P < 0.01, respectively]. Dose-normalized MPAG AUC0-12 was significantly lower in LN patients and slightly lower in Tac-treated KT recipients than in CyA-treated KT recipients [median (range), 35.0 (8.34-69.8), 51.6 (34.4-94.8), and 84.1 (34.7-152) μg·h/mL per mg/kg, P < 0.05 and P = 0.13, respectively]. The ratio of MPA AUC5-12 to AUC0-12, an estimate of MPA enterohepatic recirculation, was slightly higher in LN patients and Tac-treated KT recipients than in CyA-treated KT recipients [median (range), 0.44 (0.35-0.56), 0.45 (0.42-0.61), and 0.34 (0.22-0.55), P = 0.29 and P = 0.10, respectively]. Serum creatinine was significantly lower in LN patients than in Tac-treated and CyA-treated KT recipients. In conclusion, the pharmacokinetics of MPA in LN patients is characterized by high MPA clearance and in CyA-treated KT recipients. Despite this higher clearance of MPA, MPAG AUC0-12 was lower in LN patients most likely due to better renal function in LN patients.

Laparoscopic Nephrectomy for Atrophic Kidney Associated with Ectopic Ureter in a Child

An atrophic right kidney located in the pelvic cavity associated with an ectopic ureter was completely removed from a 4-year-old girl by laparoscopic surgery. There were no serious complications during the operation or the postoperative period. The light shining from the tip of a fine fiberscope inserted into the ureter was used to delineate this structure during laparoscopic surgery.